The above information is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form are solely my responsibility. We reserve the right to charge for appointments cancelled or failed without 24 hours advance notice. Weekdays after 4PM and Saturdays will automatically be charged. Payment is due in full at time of treatment unless prior arrangements have been approved. Balances unpaid after 90 days are subject to a late charge of 1.5% per month, and may be reported to the credit bureaus at our discretion. I understand that by signing below I accept financial responsibility for all charges whether or not paid by insurance.

HIPAA OMNIBUS RULE - Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/limited authorization & release form.
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The
undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment
activities, insurance and any other office procedures. A copy of this signed and dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A
PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your
improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this
information with your knowledge and consent.

Please print patient's name

Patient Signature (if 18 or older)

Parent / Guardian / Legal Representative Signature

Description of Authority

How do you want to be addressed when summoned from the reception area? First Name OnlyProper Sir NameOther

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

Name:

Relationship:

Name:

Relationship:

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via: